Rural Healthcare insight
Can a rural ambulance service treat a patient at home instead of transporting them?
A plain guide for EMS leaders, fire chiefs, emergency department leaders, and hospital boards: what treat-in-place is, why it stalls in rural areas, what has to change on both sides, and how the Rural Health Transformation Program is starting to pay for it.
The short answer
Yes, for the right patients, under the right protocols. Treat-in-place lets an EMS crew, usually with a physician joining by video, treat a low-acuity patient on scene, or take them somewhere other than the emergency department, instead of transporting them by default. It works clinically. It stalls in rural areas because the agency doing the work is generally paid only when it transports. Rural Health Transformation Program funding is now paying for the start-up costs while payers build a way to pay for the service itself.
What treat-in-place means
- Treat in place: the crew assesses and treats the patient on scene, with online medical control, and does not transport.
- Alternative destination: the crew transports to an urgent care, primary care clinic, health center, or behavioral health center instead of the emergency department.
- Telehealth in the field: a physician or advanced practitioner joins the call by video to support the decision.
- Follow-up: the patient is recontacted afterward, and any return to the emergency department is tracked.
Why it stalls in rural areas
- Payment. Medicare does not cover treat-in-place as a benefit; an ambulance service is generally paid only when it transports. A rural agency that treats a patient at home often receives nothing for the call.
- Federal testing ended early. The CMS Emergency Triage, Treat, and Transport (ET3) model ran from 2021 and ended early, with fewer treat-in-place and alternative-destination events than the model needed.
- Connectivity. Field telehealth needs reliable cellular coverage, which rural service areas often lack.
- Destinations. An alternative destination only works if a clinic has agreed in writing to accept the patient, and rural counties have few of them.
What has to change for EMS agencies
- Written protocols and standard operating procedures, approved by the EMS medical director and the state EMS regulator.
- A defined list of low-acuity conditions that qualify, and clear exclusions, including every trauma mechanism.
- Training in assessment, decision-making, and documentation for a call that ends without transport.
- Tablets and connectivity so a physician can join the call.
- Written agreements with alternative destinations.
- A plan to replace start-up grant funding with payer revenue or local funding.
What it means for emergency departments and regional hospitals
- A new role: providing the online medical-control physician who joins the call. This is the main new function, and the one a hospital is best placed to supply.
- Lower low-acuity volume: fewer low-acuity emergency department visits. Trauma, stroke, and inpatient work are largely unaffected, because protocols exclude them.
- Trauma criteria do not change: the regional trauma center should help write the trauma exclusions in every referring agency's protocol and review near-misses.
- Follow-up pathways: fast return and same-day clinic options, so a patient who is not transported is never left without a next step.
- Faster ambulance turnaround: fewer long transports keep ambulances in the community, which helps response times across a large rural region.
How Kentucky is funding it
Kentucky's Cabinet for Health and Family Services used its Rural Health Transformation Program funding for a "Crisis to Care - EMS Transformation" request for applications. It is a useful template for any state, hospital, or EMS agency planning this work:
- Start-up, not operations: it funds protocols, training, tablets, connectivity, medical-director time, and a program lead, up to $20 million across all awardees in year one.
- Sustainability counts: 20 of 100 scoring points go to sustainability, because payer reimbursement is still being built through the state Medicaid program.
- Partners count: written agreements with alternative destinations, and a letter from the medical director, both earn points.
- A short window: funds must be spent by September 30, 2027, roughly fourteen months from award.
Where it stands in Illinois
Illinois's Rural Health Transformation Program includes EMS Enhancement Grants (CSFA 3982), with $16.5 million in the first budget period. The money goes from Illinois HFS to the Illinois Department of Public Health and on to Resource Hospitals; it is not an open competition, and agencies cannot apply to HFS directly. Allowable uses include treat-in-place and mobile integrated care models, training, coordination, staffing, limited capital, and EMT and paramedic hiring. Whether Illinois Medicaid will pay for non-transport and alternative-destination calls has not been confirmed. Read more on how RHTP reaches EMS, fire departments, and emergency departments.
Benefits and risks for rural residents
- Benefits: avoided ambulance bills and emergency department copays, less time away from home and work, and ambulances that stay in the community.
- Risks: a serious condition missed if protocols or follow-up are weak; uneven telehealth where coverage is poor; and, under current Medicare rules, local taxpayers may carry the cost of calls that are not paid for.
Questions EMS and hospital leaders ask
Can our EMS agency start treat-in-place now?
Only with protocols approved by your EMS medical director and the state EMS regulator. Start there, then line up a medical-control physician, the technology, and written agreements with alternative destinations.
Does treat-in-place hurt the hospital?
It lowers low-acuity emergency department volume. It does not change trauma, stroke, or inpatient work, and it gives the hospital a new role as the online medical-control hub for the region's EMS agencies.
Who in Illinois receives the EMS grant money?
Resource Hospitals, through the Illinois Department of Public Health. If you are an EMS agency or a hospital that is not a Resource Hospital, the first step is a conversation with your EMS System's Resource Hospital and with IDPH, not a proposal.
Who helps EMS agencies and hospitals plan this in Southern Illinois and the Metro East?
618Today helps EMS systems, fire departments, and hospitals across the 618 area code region plan treat-in-place programs: protocols and governance, partner agreements, the funding route, and the sustainability plan that has to follow the grant.